Recently two incidents occurred in quick succession which have prompted me to write this letter. A primigravida had a Caesarean section at term at a private hospital for a breech presentation and cord prolapse. The baby was enencephalic. In another case a primigravida with no antenatal care arrived at a Government hospital in advancedlabour in the middle of the night with a big baby presenting by breech and acute foetal distress. Caesarean section was done immediately and an enencephalie baby weighing 4 kg was delivered who died soon after. In both cases the abnormality of the neural tube was not diagnosed pre-operatively. The first case Was dealt with by an experienced obstetrician but diagnosis was not made (which may be difficult at times) and Caesarean section was done unnecessarily. In the second case a pre-operative diagnosis would have been difficult and Caesarean section may have been necessary anyway in view of the large diameter of the head which has to negotiate the pelvis in enencephalic babies. The fact remains however that a congenital malformation which could have been picked up easily by investigation, was not done. Ultrasound is now freely available in most of the cities of Pakistan. It is an extremely valuable diagnostic aid in the hands of the experienced, and is safe. A single ultrasound examination by a well trained doctor in the second trimester of pregnancy would pick up morphologi cal abnormalities in the foetus like the above. A decision could then be made whether to allow the pregnancy to continue or not. It would definitely obviate the need for a Caesarean section for the sake of the foetus. It is also very important that in Government hospitals and large private hospitals where emergency patients arrive with all types of problems at all odd hours, an ultrasound should be present in the Department of Obstetrics and Gynaecology and at least one well trained resident doctor be available at all times. May I add here that unfortunately in Pakistan ultrasound has become one of the most misused diagnostic aids. it is being done unnecessarily in cases where it is not indicated and mostly by people who have had hardly any training worth its name. All sorts of bizarre diagnoses are made and handed over to the patients thus putting them in great mental and physical distress compelling them to run from one doctor to the other to allaytheir fears and anxiety. On the other hand, some doctors and patients both are so apprehensive that they do not have it done even when indicated. Thus a very valuable investigation is falling into disrepute because some are misusing it while on the other hand its full potential is not being exploited by others.
Sadiqa N. Jafarey
Dept. of Obstetrics and Gynaecology, Jinnah Postgraduate Medical Centre, Karachi.